Introduction to brushing techniques
Various brushing techniques have been advised for appropriate cleaning of teeth and removal of plaque and debris. The tooth brushing techniques which are recommended currently have been proposed in the early half of the twentieth century by various researchers. The oldest tooth brushing method was described in 1913 by Fones and is recommended mainly for children 79, 80. Every brushing technique has its advantages and disadvantages. Along with this, every brushing technique has its own indications and contraindications. Every patient should be taught an appropriate brushing technique which is recommended in that particular patient. However, an efficient plaque and debris removal is determined by the operator’s ability to satisfactorily perform a specific brushing technique. The brushing techniques are broadly classified according to the motion of the brush during brushing.
Classification of brushing techniques based on the direction of toothbrush movement
Horizontal reciprocating motion:
Horizontal Scrub Technique.
Bass (Sulcular) brushing technique.
Stillman’s brushing technique.
Charters brushing technique.
Vertical sweeping brushing technique:
Modified Bass brushing technique.
Modified Stillman’s brushing technique.
Leonard brushing technique.
Hirchfeld’s brushing technique.
Smith-Bell (Physiologic) brushing technique.
Rotary brushing technique:
In the following sections, we shall discuss in detail various brushing techniques,
Horizontal reciprocating motion
Horizontal Scrub Technique:
This is the most commonly used brushing technique due to ease of using. In this technique the bristles are placed at a right angle to the long axis of the teeth and gentle horizontal scrubbing movement of the brush is performed. The main advantage of this brushing technique is its simplicity. However, a major disadvantage of this brushing technique is cervical abrasion of teeth, which is particularly seen in patients who do vigorous brushing and/or use hard tooth-brushes.
Bass (Sulcular) brushing technique:
In this brushing technique, Bass put emphasis on the removal of plaque from the area above and just below the gingival margin 81. The brush is placed at an angle of 45⁰ to the long axis of the teeth, directed apically. The bristles are then gently pressed so that they enter the gingival sulcus and interdental embrasure. This action should produce perceptible blanching of the gingiva. The brush is then vibrated gently back and forth with short strokes. At each position, 20 strokes are given and then …………. Contents available in the book …………. Contents available in the book …………. Contents available in the book …………. Contents available in the book ………
- This tooth brushing technique is indicated in all patients for bacterial plaque removal adjacent to the areas directly beneath the gingival margin.
- Open interproximal areas, cervical areas beneath the height of contour of enamel and exposed root surfaces.
- For patients who had periodontal surgery, but not immediately after surgery.
The main advantage of this technique is that short back and forth motion is easy to master because most of the patients usually use the scrub brushing technique. Also, this brushing technique concentrates the cleaning action on the cervical and interproximal portion of teeth, which have maximum plaque and debris accumulation.
The disadvantage of this brushing technique is that the patient has to place the brush in many different positions to cover the full dentition. Hence, the patient may loose patience while performing this brushing technique. To overcome this problem, the patient should be instructed to brush in a controlled and systematic sequence for optimum plaque removal.
Stillman’s brushing technique:
This technique is similar to the Bass technique except that the bristles are placed partly over the cervical portion of the teeth and partly on the adjacent gingiva. As compared to Bass technique where the bristle ends enter the gingival sulcus, the Stillman’s technique uses sides rather than the ends of the bristles and penetration of the bristles into the gingival sulci is avoided. The brush is placed in the same manner as described for Bass technique, i.e., at 45⁰ angle apically to the long axis of the teeth. The brush is activated with 20 short back-and-forth strokes and is simultaneously moved in a coronal direction along the attached gingiva, gingival margin, and tooth surface.
- For spongy gingival tissue where massaging is valuable.
- For cleansing areas with the progressive gingival recession and root exposure to minimize abrasive tissue destruction 82.
The advantage of this brushing technique is that it provides gingival stimulation along with plaque and debris removal from cervical margins of the teeth and wide embrasures.
Similar to the Bass technique of tooth-brushing, this technique requires patience for placing the toothbrush in many different positions throughout the dentition.
Charter’s brushing technique:
This brushing technique of tooth-brushing was recommended by Charter in 1848 83. It is a very useful technique for patients having fixed prosthodontic or orthodontic appliances and in patients who recently underwent periodontal surgery. In this brushing technique, the brush is placed at an angle of 45⁰ to the long axis of the teeth in an opposite direction as recommended in Bass technique, i.e., the bristles are directed coronally. After adaptation of the brush in place, the bristles point away from the gingiva but towards the interproximal surfaces of the teeth. After placing the bristles at the gingival margin, short back and forth vibratory strokes are given. The bristles of the brush are then pressed on the occlusal surfaces of the teeth and using a slight rotary motion, pits and fissures are cleaned.
- This brushing technique aids in cleansing the fixed orthodontic appliances.
- It helps in loosening of debris and bacterial plaque.
- It massages and causes stimulation of marginal and interdental gingiva.
- This brushing technique is indicated following periodontal surgery.
- This brushing technique is useful in removing bacterial plaque from the abutment teeth and under the gingival border of fixed partial denture or from the under surface of sanitary bridges.
- This brushing technique is also suitable for cervical areas below the height of contour of the crown and to the exposed root surface.
This technique is specifically indicated in patients having fixed prosthodontic and orthodontic appliances because it efficiently removes plaque and debris from these appliances. After periodontal surgeries, this technique gently massages the area of wound healing and promotes healing.
The main disadvantage of this brushing technique is that …………. Contents available in the book …………. Contents available in the book …………. Contents available in the book …………. Contents available in the book ………
Vertical sweeping brushing technique
Modified Bass brushing technique:
The modified Bass technique is same as the Bass technique with one additional movement of the bristles. After the vibratory motion has been completed in each area, the bristles are swept in rolling motion towards the occlusal surface. The indications are the same as discussed earlier under Bass technique.
This technique allows the removal of plaque and debris from the sulcular and interdental areas. Along with this, the rolling motion completely cleans the buccal and lingual surfaces of the teeth without damaging the base of the gingival sulcus. This technique is recommended for patients with healthy gingiva without the recession of gingival margins.
This technique is difficult to master and repeated patient reinforcement is required.
Modified Stillman’s brushing technique:
The technique is same as described in Stillman’s technique with the addition of a sweeping movement of the bristles in a coronal direction. The technique is indicated in patients with gingival recession, as it provides good gingival massage. Indications are the same as discussed in Stillman’s technique.
This technique offers good gingival massage and inter-proximal cleaning.
The technique is difficult to learn and implement.
Leonard brushing technique:
It is a vertical tooth brushing technique where the brush is moved up and down across the teeth. The maxillary and mandibular teeth are brushed separately. After bringing the upper and lower teeth in edge to edge contact, the bristles are placed at a right angle to the long axis of the teeth and are moved in up and down stroke motion. It must be noted that the upper and lower teeth are not brushed in the same stroke. The teeth are placed in edge to edge contact to avoid slipping of the brush over the incisal or occlusal surfaces. Pressure, enough to force the filaments into the interdental areas is applied, but soft tissue should not be injured by excessive pressure.
This technique is not as efficient in plaque removal as the modified Bass or modified Stillman’s technique. However, if the patient is using this technique and is able to …………. Contents available in the book …………. Contents available in the book …………. Contents available in the book …………. Contents available in the book ………
Hirshfeld’s brushing technique:
This brushing technique is essentially the same as the Charter’s technique except that the maxilla and mandible are kept occluded. It provided additional stability and control for those patients who lack manual dexterity. The cheeks help in exerting pressure required to flex the bristles.
Smith-Bell (Physiologic) brushing technique:
This is also known as the physiological technique of tooth-brushing because the brushing method is the same as that taken by the food during mastication. The bristles are placed at the height of the incisal edge or occlusal surfaces at an angle of 90 degrees and moved in the gingival direction. This brushing technique produces frictional action similar to that obtained from mastication of fibrous food. This brushing technique is suitable for patients having anatomically normal dentition. It stimulates the gingiva and improves blood circulation in the connective tissue. However, in the existing pockets, this brushing technique tends to strip the tissue away from the teeth and facilitates packing of debris into the open pocket.
Rotary brushing technique
This method is usually recommended for young children with minimal manual dexterity. The technique is quite easy to learn and provides good gingival stimulation. In this technique, the brush is placed against a set of teeth and is moved in a circular motion 4-5 times for each set of teeth. The maxillary and mandibular teeth are kept in occluded position while performing this brushing technique. This technique is simple to use, but is less effective than modified Bass and modified Stillman’s technique in plaque and debris removal.
Sequence of brushing
The recommended procedure for brushing is to start brushing from molar region of one arch and then moving towards the opposite molar region of the same arch. Then the lingual surfaces of the same arch are cleaned. The same procedure is followed on the opposite arch until all the accessible areas of the dentition are cleaned. The last surfaces to be brushed are the occlusal surfaces.
Frequency of tooth-brushing
There has been no consensus so far regarding the frequency of tooth-brushing. Studies designed to evaluate the association between frequency of brushing and development of gingivitis have not come up with any consensus on a particular daily frequency of brushing which may prevent the development of gingivitis 84-87. It has been emphasized that the development of gingival inflammation is more related to the quality of tooth brushing rather than the frequency of tooth brushing 88. In other words, we can say that an appropriate brushing technique (indicated for that particular individual) carries more importance than frequency of brushing.
However, brushing teeth twice daily has been recommended as a measure for maintaining good oral hygiene 89. Three or more cleanings per day did not produce significantly better periodontal conditions. It has been suggested that one of the two brushings done in a day should be performed very thoroughly to maintain a good periodontal health. Tooth-brushing should be performed most preferably after taking meals. A dry brush without debris between the bristles should be used. Keeping two …………. Contents available in the book …………. Contents available in the book …………. Contents available in the book …………. Contents available in the book ………
The length of time for which one brushes teeth varies from person to person depending on the technique of brushing and the manual dexterity. Initially, when a tooth-brushing technique is instructed to a patient, usually 10-20 minutes brushing time is required until the patients learn the technique. Once the patient adapts to the technique, 3-5 minutes are sufficient for brushing.
How to clean and store a toothbrush
A clean toothbrush is the primary requirement for the maintenance of good oral health. The toothbrush should be rinsed with hot water before and after brushing the teeth. The thumb should be placed over the bristles and moved back and forth with light pressure underneath or in water. This procedure should be done both before and after tooth-brushing because many airborne bacteria and other particles such as dust may have settled on the toothbrush since the last brushing. The brush should be kept in a dry place which is well ventilated so that its bristles dry soon after brushing. A dry environment is not conducive for the growth of many bacteria and fungi.
Except for traveling, the brush should not be stored in any closed container where it does not receive adequate ventilation. Also, the bristles of the toothbrush should not come in contact with the walls of the container as this may contaminate the bristles. The brush should be stored in an upright position so that the drainage of water from the bristles is facilitated. The toothbrush holder should be cleaned on a regular basis because the water that drains from the bristles gets collected where the handle touches the toothbrush holder and is a potential source of infection. Toothbrushes should not be swapped. To avoid swapping, color coding or writing names may help. Finally, the brush should be replaced on a regular basis within 2 to 3 months or before it starts showing the signs of fraying, irrespective of how long it has been used. As already discussed, most of the brushes have their bristles coated with a dye which fades with use. It acts as a good indicator for toothbrush replacement.
Many toothbrush sanitizers have been introduced which utilize UV light, antibacterial rinses and even some toothbrushes with antibacterial bristles have been designed. However, their efficacy in toothbrush sanitization still needs to be established.
Dentifrices are an integral component of plaque control and are used to deliver various chemical agents to control plaque. A detailed description of dentifrices has been given in “Chemical plaque control”.
Assessment of home care:
The assessment of plaque control by the patient plays an important role in the maintenance of good oral hygiene. The most effective tool in the assessment of plaque control is disclosing agents. Read “Disclosing agents” for more details.
Brushing of teeth is the most common technique of maintaining adequate oral hygiene. It is practically the most effective technique used for the removal of plaque biofilm from tooth surfaces. However, inappropriate brushing may damage the tooth structure and the soft tissue surrounding the teeth. Hence, following an accurate brushing technique is essential to maintain good oral hygiene as well as preventing damage to the soft tissue surrounding the teeth. Every individual should be evaluated before advising him/her about a particular brushing technique.
References are available in the hard-copy of the website.